It’s fair to say politicians can’t always be trusted but Labor health spokeswoman Catherine King was pretty much on the money with this observation in her debate with Health Minister Greg Hunt at the National Press Club on Thursday.

“This election offers a stark choice and nowhere is that choice more stark than when it comes to health policy.”

Labor has been rolling out policies for months that address big gaps in health care and social determinants of health. It has made commitments ranging from affordable and remote housing to oral health, and is promising systemic reform, a review of private health, and now a focus on prevention that we have not seen in years.

By comparison, the Coalition,which took an axe to critical health areas when it came to office in 2014, continues to focus on hospitals and medicines, to see critical parts of the system as silos, and to not question growing costs and problems with private health.

That’s not to say Labor gets it all. The proof will be in the implementation if it wins government and, as health experts point out in the verdicts below, significant policy issues were missing in action in Thursday’s debate, including any mention of climate change.

The rural health sector was particularly dismayed at the lack of focus on rural health issues – a big equity issue.

Given the big picture approach in the Greens health plan, which so many health groups have welcomed, including them at the podium would have opened up the debate on these and other equity issues.

Laying out the positions

Hunt emphasised investments in hospitals and his government’s record on listing more medications on the Pharmaceutical Benefits Scheme, and how much they depended on a strong economy that he suggested only the Coalition could deliver.

He said the cost of new medicines is “the biggest single out-of-pocket cost that people can face” (King noted the Coalition had previously tried to bring in a PBS copayment) and that Labor could not be trusted on the PBS.

“We know we need a strong economy to be able to do these things, to save lives and protect lives,” Hunt said.

(See below for concerns from Society of Hospital Pharmacists of Australia that the “rhetoric” in commitments to reducing the cost of new and improved medicines belies $44 million cuts to hospital pharmacy – a “hidden detail” in last month’s Budget.)

The Minister pledged his unwavering commitment to private health care and insurance and issued a media release after the event saying that Labor has “refused to rule out whether it will rip the private health insurance rebate away from more Australian families and pensioners”.

Labor has promised a two per cent cap on private health insurance premium increases for two years and to order a “root-and-branch” Productivity Commission review of the private health system.

Pressed on this policy, King said the private health system overall is “in trouble” with demand declining, but she was “not going to rule in or out what the Productivity Commission might or might not recommend nor what our response might be.”

In her opening comments, King outlined a broad suite of policies, including the $2.4 billion Pensioner Dental Plan, $2.3 billion cancer package, and $2.8 billion pledge for hospitals that would restore a 50-50 public hospital funding deal with the states.

“This is the $7.5 billion dividend of the hard choices we’ve made in Opposition,” she said.

Earlier on Thursday she announced a $115.6 million investment in prevention, including a national obesity plan, which has won big applause from key medical and health groups although disappointment from the Australian Medical Association (AMA) that it did not include a sugar tax (see more below).

“So yes there is a stark choice on May 18 but…if you care about health care, then there really is no choice at all,” she said.

Some, and too much agreement

Despite fundamental differences in principles and policies on offer from Hunt and King, there was some agreement and matching of policies – and critique from health experts that they both were too focused on hospitals and medicine and not enough on the social determinants of health and climate change. See their verdicts below.

Ahead of the debate, the Coalition announced it would invest $308 million to cut the cost of life changing prescription medicines for over 1.4 million Australians with chronic conditions who require multiple medicines. Labor said it would “adopt” the policy, and reaffirmed its Affordable Medicines Guarantee – a commitment to list every drug recommended by the independent experts.

Labor also matched the Coalition’s promise, made earlier this week in response to an urgent call from health and medical groups, to establish a national taskforce and strategy on industrial dust diseases to address alarming rates of accelerated silicosis, a preventable lung disease occurring in workers as a result of exposure to silica dust.

Hunt and King agreed, heartily, on continued opposition to introducing vaping in Australia as a tobacco control measure, although King, applauding Hunt’s strong stand, warned that other members of the Coalition were lobbying in favour of e-cigarettes.

Hunt said there was an “epidemic” of vaping among young people in the United States. He said:

“What has occurred is a public health disaster and that’s not something I’m prepared to countenance on my watch. It is far more a case of being a ramp on rather than a pathway off smoking.”

And both fudged their responses to health journalist Sue Dunleavy’s question on why the government rejected a Pharmaceutical Benefits Advisory Committee recommendation that doctors be able to prescribe people with chronic illnesses medicines for two months.

“It would have saved the taxpayer many millions of dollars, because we wouldn’t have to pay as much dispensing fees,” Dunlevy told Hunt. “You backed down on a decision to act on that after the Pharmacy Guild ran some ads in major newspapers just before the budget.”

Asked in another question to say when they had stood up to industry interests for the sake of Australian patients, Hunt nominated the government’s decision to require prescriptions for codeine, against the wishes of the pharmacy industry, which we learnt last week had resulted in a halving the number of codeine products supplied in Australia in 2018.

King nominated the private health insurance premium cap, and introduction of Health Star ratings for food which she is considering making mandatory, versus Hunt’s preference for a voluntary system.

Verdicts on the debate

Consumers Health Forum of Australia CEO Leanne Wells

Wells said the debate provided a rare and welcome opportunity for the rival health policies to come under scrutiny but also demonstrated there is “a patchwork of piecemeal proposals” to fix various problems in the system. She said:

“Both speakers put hospitals and medicine first. Neither spoke of the social determinants of health, such as housing, education and employment, which have such an impact on health.

“What we want to see is prevention and transformative primary care being central to the vision for better health in Australia.

“Each side is offering different initiatives…. The two parties’ views on a variety of issues ranging from mental health, to health insurance rebates to codeine regulation, highlight the diversity of costly and complex issues that bedevil health care.

“What Australian health consumers need now is a more joined up approach that gives much more emphasis to integrated care in the community.”

Jennifer Doggett, chair of the Australian Health Care Reform Alliance and Croakey editor

“One thing that stood out to me was how Greg Hunt doesn’t really see health care as a ’system’ – he really just sees it as an aggregate of individual services provided to individual consumers. He focusses on the listing of ‘life saving drugs’ on the PBS and the medical research being undertaken into new treatments as though these exist in some isolated way outside of other parts of the health system.

“He doesn’t seem to have any conception of the importance of health care being a coherent system of different types of services. It’s a very individualistic and atomistic approach and completely ignores the fact that many of the problems in health care are due to the way different services and programs interact (or don’t) to meet the complex needs of consumers.

Catherine King seemed to have a bit more idea about health care as a system and talked about the need to get primary health care more integrated into prevention and the need to address mental health across the spectrum of the health system. She also acknowledged the need for some fundamental reforms and has a strategy to come up with these (the proposed Australian Health Reform Commission).

Hunt seems to be under the delusion that there isn’t a problem with the way we fund and deliver health care – for him it’s just a matter of keeping the economy strong and paying the bills.

Neither mentioned social determinants or climate change and the importance of these to health. Also, while both of them acknowledged the importance of mental health, neither of them could really answer the question about why headspace doesn’t seem to be delivering the results expected from it – although King did identify that one issue may be the lack of integration with primary health care.

Hunt’s failure to address the question on out-of-pocket costs was pretty breathtaking. Given it has been such a high-profile issue and that he personally established a Ministerial Advisory Committee on this issue you would think he would at least have a response or talk up what he had done.

It was also clear from their responses that neither potential minister are going to say anything to antagonise the AMA or Pharmacy Guild – at least pre-election. This does limit their ability to promote reforms to move from a provider to a consumer centred system.

Dr Tony Bartone, president Australian Medical Association

The AMA has called on King and Hunt to announce the missing pieces from their health care vision, including big gaps on aged care and broad mental health strategies.

“There has been a lot of talk about mental health, but not much genuine action,” Bartone said, though he welcomed the commitment to primary care from both parties (and King’s promise that primary health care reform would be one of the priorities of the Health Reform Commission) and Labor’s announcement on prevention.

“Minister Hunt never moves beyond talking about PBS listings linked to a strong economy (although PBS costs are flat lining), hospitals (despite cuts to the promised rates of increased funding), Medicare (misstating what bulk billing rates mean) and biomedical research (with the Medical Research Future Fund funded by cuts to health and Indigenous affairs), although he is focused too on mental health and tobacco control.

“Labor clearly has a full suite of policies and Catherine King is across them. The only question is: will a Labor Government be brave enough to implement them and drive meaningful reform? I would have liked to have heard more in the debate about out of pocket costs, especially for the chronically ill, addressing health disparities, workforce issues and how to reward doctors for time taken to deliver care coordination etc.”

Verhoeven said the Coalition, Labor, and the Greens are all promising welcome extra health dollars and reduced out-of-pocket costs for electors should they win government—but public commitment to getting better value for those dollars has been muted.

‘For example, do you really need that extra appointment with the doctor to renew a script or have a specialist referral updated? Do you really need to pay a GP to carry out a treatment or give an injection when a trained nurse can do it just as effectively? Why are some treatments still subsidised by Medicare when more effective evidence-based treatments are available? Why get that injury treated in hospital when it could be done just as well at your local primary care clinic for a fraction of the cost?

‘We need to shift the whole system to value-based healthcare—that is, better outcomes for patients relative to costs—or the right care in the right place at the right time by the right provider.”

See more detailed AHHA commentary on Coalition and Labor policies here.

National Rural Health Alliance CEO Mark Diamond

Diamond said the Alliance was “dismayed” at the lack of focus on rural health issues in the debate.

“It’s fair to say that the health needs of over 7 million people were totally ignored in this debate,” he said.

“Why is it that we have 28% of the population experiencing 1.3 times the total burden of disease and yet successive governments don’t give it priority and they certainly didn’t in yesterday’s national debate. Where was the focus on rural health?”

Diamond said last month’s 15th National Rural Health Conference in Hobart highlighted Indigenous health, access to health care, research and the need for a new National Rural Health Strategy as critical election issues.

“Labor has committed to developing a new rural health strategy and we welcome this but we heard nothing on this or any of these other points in yesterday’s debate.

“The situation is now reaching crisis point. We just don’t have sufficient workers in rural and particularly remote areas to meet the health needs of the population. People are dying as a result.

“We have some areas in Australia that do not have access to basic services. The Royal Flying Doctor Service has identified 15 regions that do not have access to psychological services because the psychologists just aren’t there.

“What sort of world do we want to live in when the disparity in access to timely, appropriate and affordable health care is so disproportionate to need?

“Suicide rates in rural Australia are 40 per cent higher than in metropolitan areas yet less than half the funding to address this is distributed there. What is happening here?

“To date the Greens are the only party to have issued a specific statement on what they plan to do for rural health and we commend them for that.

“The lack of focus on rural health is just so disappointing – we know that Catherine King represents a regional seat. We know that Greg Hunt’s electorate borders on an outer metropolitan area.

“There is no excuse for them – they know the disparity in access to health care experienced by rural Australians. They know. We call upon them to commit to what the sector is saying about the health of people in country areas. Commit to the Alliance platform.”

Rural doctors also criticised both Hunt and King for a debate “that showed no sign of interest in rural health”.

Both Coalition and Labor have announced funding for a National Rural Generalist Pathway, but Hall said that this was “no silver bullet that will magically solve all of the issues facing the provision of healthcare in the bush”.

Apart from that, rural health issues have not rated a mention in the election campaign to date and were nowhere to be seen in the debate, he said.

“Despite a lot of talk, rural health continues to be a policy black hole in the upcoming election,” he said.

See the RDAA statement which lists a number of urgent needs and ways to address them.

“Visionary policies and renewed commitments to reducing the cost of new and improved medicines were front and centre at (the) Health Debate at the National Press Club, however the rhetoric belies $44m in cuts to hospital pharmacy, potentially putting 500 jobs at risk,” Michaels said.

The SHPA said a hidden detail of the 2019 Federal Budget will cut funding to the PBS through a reduction in funds being paid to hospitals, from 1 July 2019.

“The Improving Access to Medicines – supporting community pharmacy measure will slash the mark-up paid to public and private hospitals to support treatment with PBS medicines and medicines safety activities – from 11.1% to 7.52% – cutting millions of dollars from hospital budgets that are used to support the management of PBS medicines to patients being treated after heart attacks, stroke, life-threatening infections and during chemotherapy.”

“On behalf of our members, SHPA has been speaking to all major parties, yet we are yet to see evidence of any measures to reduce the negative impact of these cuts.

‘The PBS is an invaluable mechanism improving equity of medicines access for all Australians, but it must be funded appropriately to ensure high quality patient care, and that includes pharmacy review, counselling and medicines management.

‘Rather than quietly cutting funds to the people who are experts in medicine management in acute settings, the government should be increasing support for hospital pharmacies to ensure that, as more and more complex medicines are added to the PBS, they can be used optimally and provided to more patients as effectively as possible.

“Prevention is better than cure”

implement Australia’s first National Obesity Strategy, including specific plans to increase physical activity and improve nutrition, and consideration of mandating the Health Star Rating system and food reformulation targets

review junk food advertising to children to ensure the regulatory framework is “fit for purpose in the contemporary media environment”

invest $40 million over four years to reboot Australia’s National Tobacco Campaign, aiming to drive Australia’s smoking rate below 10 per cent

finalise a new National Alcohol Strategy, invest $10 million over four years in targeted campaigns to reduce harmful drinking, such as the successful Pregnant Pause and Women Want to Know campaigns, deliver pregnancy warning labels on alcohol packaging and work to reduce children’s exposure to alcohol advertisijng.

develop an Australian model of the First 1,000 Days program, building on the existing world-leading work among Aboriginal and Torres Strait Islander families. This will include a whole-of-government taskforce, headed by a new Chief Paediatrician role in the Health Department, as well as an expert advisory group.

develop, in collaboration with consumers and experts, a national platform for consumer information on health and wellbeing, building on existing models such as Victoria’s Better Health Channel.

King said these commitments to preventive health build on other pledges such as Labor’s commitment to develop the first National Strategy on Climate Change and Health.

The Public Health Association of Australia gave the package four out of five stars, but said “implementation will require courage to stand up to influential commercial interests”.

PHAA CEO Terry Slevin said the Federal Coalition, which cut about $1 billion cut from the Health Department Flexible Funds and abolished the National Preventive Health Agency, had “dropped the ball on prevention”.

AHHA Chief Executive Alison Verhoeven said the package deserved “a big tick for refocusing attention on health improvements for the health dollar, rather than health service activity”.

The AMA welcomed the package but with some reservation and disappointment. President Dr Tony Bartone said the broad range of prevention initiatives is welcome, but will ultimately require significantly greater funding to be effective for the long term.

“The AMA has also been demanding urgent action on obesity, and the measures announced by Labor represent an important first step, but tougher and more robust actions are needed. It is disappointing that Labor did not take the opportunity to introduce a sugar tax.

There was applause from the Royal Australasian College of Physicians (RACP) which said the ambitious plan “ticks a lot of boxes” in preparing Australia for future health challenges, to address inequity and stop people getting sick in the first place.

“There is a lot in this announcement – many of the things that we’ve been campaigning for over a number of years. We’ll take the time to look over it closely,” said RACP President, Associate Professor Mark Lane, who highlighted plans to appoint a National Chief Paediatrician, whole of government task force to develop a national First 1,000 days program, and establish a national task force to address the accelerated silicosis epidemic as particularly welcome.

In its pre-election statement, the RACP identified sustainability, prevention and equity as three key interlocking priority areas, advocating for a sustainable healthcare system, greater investment in preventative health and a stronger focus on ensuring equity and access for all Australians.

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